Urinary incontinence in the female
1. Definition 8. Investigations
2. Stress incontinence 9. Management-
3. Prevalence Genuine stress
4. Pathophysiology incontinence
5. Causes Detrusor instability
6. Clinical presentation
7. Physical examination
Involuntary loss of urine which is
objectively demonstrable & is a social or
Stress incontinence: Involuntary expulsion of
urine under conditions of stress like rise of
intra-abdominal pressure due to coughing,
sneezing , laughing or lifting weights.
Upto 57% in women 45-64 yrs.
14% in general population.
Common condition, but rarely life
Adverse effect on quality of life
Embarrassment and anxiety.
Pathophysiology of stress
1. Intravesical 2. Detrusor pressure
pressure exceeds excessively high i.
urethral pressure e. Detrusor
because of Instability or
urethral sphincter Hyper-reflexia of
mechanism i.e. Bladder.
Causes of urinary incontinence
1. Genuine stress 2. Detrusor instability
3. Retention with overflow
weakness of bladder incontinence
neck, denervation of
4. Urogenital fistula
of pelvic floor (during 5. Temporary – UTI,
delivery), estrogen drugs-α-blockers.
deficiency in 6. Urethral diverticulum
7. Congenital abnormalities- ectopic ureter,
bladder exstrophy etc.
8. Functional /neurologic disorders- dementia,
spinal lesions, space occupying lesions in
Stress incontinence- Detail history- prolapse,
most common. obstetric history,
Associated features- recurrent UTI, episodes
urgency, frequency, of retention etc.
dysuria, urge H/O diabetes, drugs –
incontinence, voiding diuretics, α-blockers etc.
difficulties- poor stream, Neurological symptom
With full bladder in stress incontinence.
Local- excoriation of vulval skin.
Atrophic changes, cystocele, prolapse.
Bladder neck elevation test(Marchetti test)- To
see whether surgery will benefit or not.
Mental state, developmental anomalies,
General Basic Urodynamics
i. Urine- i. Uroflowmetry- 15-
opy, c/s ii. Cystometry-
ii. Frequency/volume differentiate betn GSI
chart or urinary diary. &DI- Intravesical
iii. Pad test. pressure during filling ,
if > 15cm water after
250 ml DI
Residual urine- <5oml. Videocystourethrography
First sensation of urge Combines cystometry,
~250ml. If earlierurge uroflowmetry &
incontinence. radiological screening of
Bladder capacity- 500- bladder & urethra.
600ml. If Most informative, but
Metallic bead chain USG- position &
urethrocystogram excursion of bladder
Urethral pressure neck.
profilometry. Electromyography of
Cystourethroscopy. pudendal nerve.
Micturition cystography Urethral electric
Management of GSI
a. Kegel’s exercises of pelvic floor muscles.
b. Wt. Reduction in obese patients.
c. Treat chronic cough, UTI.
d. Faradism- interrupted current to stimulate
muscles & nerves.
e. Drugs- Estrogen, α adrenergic agonists-
90% cure rate.
Elevate bladder neck & proximal urethra into
intra-abdominal position, support the bladder
a. Anterior colporrhaphy with Kelly suture.
b. Marshall-Marchetti-Krantz operation-
Surgical management (contd…)
c. Burch colposuspension.
d. Pereyra procedure.
e. Sling procedures- secondary- Stamey, Raz
f. Artificial sphincter implant.
g. GAX-collagen- periurethral injection.
h. Urinary diversion- Last.
Spontaneous or provoked detrusor
contractions during the filling phase when the
pt. Is attempting to inhibit micturition.
Urgency, urge incontinence, enuresis,
No specific clinical signs.
Management of DI
1. Behavioral interventions.
2. Drugs- most widely used- anticholinergic agents-
oxybutynin, propantheline., calcium channel blocker-
terodiline, Tricyclic antidepressant-imipramine,
αadrenergic stimulants., estrogen, synthetic
3. Denervation- phenol injection, bladder transection,
vaginal denervation, sacral neurectomy.
4. Cystoplasty- clam ileocystoplasty.